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PubMed1998

Betamethasone reduces postoperative pain and nausea after ambulatory surgery.

UNLABELLED: The aims of this study were to evaluate the effects of a single-dose glucocorticoid on the incidence and severity of pain and nausea and vomiting (PONV) after ambulatory surgery. Seventy-eight ASA physical status I-III patients scheduled for hemorrhoidectomy or hallux valgus correction were studied using a randomized, double-blind, placebo-controlled protocol. One group received 12 mg of betamethasone i.m. 30 min before the start of surgery (Group B), whereas the placebo group (Group P) received saline. General anesthesia was induced with propofol and fentanyl and maintained with isoflurane in both groups. Pain (measured using a visual analog scale, verbal score, and analgesic requirements), PONV, and other side effects were evaluated postoperatively. Patients in Group B experienced significantly less postoperative pain, less PONV, and better patient satisfaction during the first 24 h after surgery. In conclusion, a single dose of betamethasone (12 mg) seemed to produce analgesic and antiemetic effects after day-case surgery. IMPLICATIONS: In a placebo-controlled study, the use of corticosteroid prophylaxis (betamethasone) produced a significant reduction in both postoperative pain and nausea in outpatients who received the corticosteroid injection before ambulatory foot or hemorrhoid operations.

Adult↗
PubMed2001

Sutureless closed hemorrhoidectomy: a new technique.

OBJECTIVE: To compare a new technique of radical hemorrhoidectomy using an electrothermal device originally devised to seal vessels in abdominal operations, with the conventional open Milligan-Morgan procedure performed with diathermy. SUMMARY BACKGROUND DATA: Hemorrhoidectomy is one of the most commonly performed anorectal operations. Two well-established methods, the "open" Milligan-Morgan excision and the "closed" Ferguson technique, both carry risks of postoperative bleeding, urinary retention, and late anal stenosis. The convalescence is similarly long and difficult after both operations. The quest for an improved technique of radical excision of hemorrhoids is justified. METHODS: In this case-control study, two groups of patients were alternatively allocated into study and control groups. In the study group (n = 40), an electrothermal system was used. The tissue fusion produced by this device consists of melting of collagen and elastin. This technique essentially achieves a sutureless closed hemorrhoidectomy. The operative time, postoperative complications, and time off work were compared with the group undergoing conventional Milligan-Morgan hemorrhoidectomy (control group, n = 40). RESULTS: The operative time and time off work were significantly shorter in the study group. There were also fewer postoperative complications in this group. CONCLUSIONS: The "tissue-welding" properties of this device and the shape of the electrode handpiece may be successfully applied to the performance of an operation most appropriately described as a "modified sutureless closed hemorrhoidectomy." This pilot study shows that this new technique is simple and safe, significantly shortens the operation, and is followed by a significantly easier and shorter recovery.

Adult↗
PubMed1998

Primary colon cancer without gross mucosal tumor: unusual presentation of a common malignancy.

Colon cancer typically arises in the colonic lumen, allowing for endoscopic detection of cancerous and premalignant lesions. In the case presented, a 73-year-old man with iron deficiency anemia had two colonoscopies showing only diverticula and internal hemorrhoids. Three years later, when the patient complained of dull, intermittent lower abdominal pain, a third colonoscopy identified diverticula, three adenomatous polyps, and no other abnormality. Computed tomography (CT) of the abdomen revealed a 5 cm x 6 cm pericolic fluid collection, which was later found to communicate with the sigmoid colon. The surgical specimen from a partial colectomy contained a distal sigmoid perforation with a 2.5 cm moderately differentiated adenocarcinoma in the underlying submucosal tissue. There was no gross intraluminal tumor. Histopathology, including immunohistochemistry, was consistent with colonic adenocarcinoma. Primary colon cancer grossly sparing the mucosa is an unusual presentation for this common malignancy.

Adenocarcinoma↗
PubMed2004

Prevalence of occult celiac disease in patients with iron-deficiency anemia: a prospective study.

BACKGROUND: Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study. METHODS: Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998-2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin < 25 ng/ml and anemia with hemoglobin < 12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery, overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease. RESULTS: One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett's ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients. CONCLUSION: The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.

Anemia, Iron-Deficiency↗
PubMed2005

Anesthetic effect of epidural anesthesia with cephalad or caudad catheterization for ankle surgery or hemorrhoidectomy.

BACKGROUND: The larger size of the first sacral nerve root has been reported to be an unfavorable factor leading to sacral sparing in epidural anesthesia. Previous studies have shown that an adequate analgesic effect of the epidural block was achieved with the catheter placement in the caudal direction. In this study, the anesthetic effect of epidural anesthesia with catheter placement of a cephalic or caudad direction was compared in ankle and hemorrhoid surgery. METHODS: Twenty-one ASA physical status I or II patients undergoing surgery for ankle fractures with epidural anesthesia were enrolled and randomized into two groups. The epidural catheter was placed either to a cephalad (AU group) or caudal (AD group) direction. Another 21 patients undergoing hemorrhoidectomy were also randomized into two groups to receive epidural anesthesia in a similar way (HU and HD groups). The onset for, duration of, and recovery time from epidural anesthesia and the incidence of analgesic request were recorded. RESULTS: No significant differences were demonstrated when age, height, weight or sex were compared between the four study groups. The onset time of the block and the incidence of intrasurgical analgesic request were lower in the caudal subgroup when the ankle surgery patients were compared. Otherwise, there were no significant differences in the duration of anesthesia and time to recovery or level of anesthesia. CONCLUSION: Injection of local anesthetic solution through a caudally oriented epidural catheter produces faster onset and superior quality of anesthesia in comparison with the injection through the cephaladly oriented catheter in ankle surgery, but not hemorrhoidectomy.

Adult↗
PubMed1998

The outpatient evaluation of hematochezia.

OBJECTIVE: The objective of this study was to determine whether specific clinical symptoms associated with hematochezia are predictive of important GI pathology and whether full colonoscopic examination is necessary. METHODS: A total of 103 outpatients (> or = 45 yr) with hematochezia, defined as the passage of bright red blood per rectum, underwent anoscopy and colonoscopy. Before endoscopy, patients completed a detailed interview, quantitating the amount and frequency of bleeding, weight loss, use of aspirin/NSAIDs, change in bowel habits, family history, and prior GI illnesses. Based on this information, physicians were asked to predict whether the bleeding was from a perianal or more proximal site. At colonoscopy, pathology was stratified as either proximal or distal to the sigmoid/descending junction. Substantial pathology was defined as one or more adenomas > 8 mm, carcinoma, or colitis. RESULTS: Anoscopy demonstrated internal and external hemorrhoids in 78 and 29 patients, respectively. On colonoscopy, 36 patients had 43 substantial lesions. Thirty-seven of these lesions were distal to the junction of the descending and sigmoid colons and six were proximal lesions. Four patients had cancer; all were distal lesions. Patients with substantial lesions were more likely to give a history of blood mixed within their stool (p = 0.03), to have more episodes of hematochezia per month (p = 0.008), and to have a significantly shorter duration of bleeding before medical evaluation (p = 0.02) than did patients without such lesions. However, the physician's clinical assessment did not predict reliably which patients were likely to have substantial pathology. CONCLUSIONS: In patients with hematochezia, clinicians were unable to distinguish between those patients with and those without significant colonic lesions by history alone. Flexible sigmoidoscopy would have demonstrated most (95%) substantial lesions. The lesions that flexible sigmoidoscopy missed were an unlikely cause of bleeding in this small group of patients.

Ambulatory Care↗
PubMed1999

Comparison of the color of fecal blood with the anatomical location of gastrointestinal bleeding lesions: potential misdiagnosis using only flexible sigmoidoscopy for bright red blood per rectum.

OBJECTIVE: Flexible sigmoidoscopy has been recommended for diagnosis of patients with bright red rectal bleeding. The purpose of this study was to determine whether lesions associated with bright red hematochezia are located in the distal 60 cm of the colorectum and, therefore, in reach of a flexible sigmoidoscope. METHODS: Three hundred-twelve consecutive patients presenting with hematochezia were shown a card containing three shades of red and asked to choose the color most representative of their fecal blood. Patients then underwent colonoscopy. The colonoscopist noted the length of the scope inserted when bleeding lesions were found. RESULTS: Of 217 patients with bright red hematochezia, 181 bled from the distal 60 cm of the colon, 20 had more proximal lesions (including eight with cancer), and 16 had no lesion found. However, 140 patients with rectosigmoid neoplasms or nonbleeding nonneoplastic lesions (e.g., hemorrhoids, diverticula, vascular anomalies, and fissures) if found by sigmoidoscopy would have subsequently required full colonoscopic surveillance. It was calculated that the average per patient medical charges employing an initial colonoscopic approach would save $12 or $116 over one beginning with sigmoidoscopy (depending on whether sigmoidoscopy is performed in an office setting or endoscopy suite, respectively), and would reduce the probability of perforation slightly. CONCLUSION: A diagnostic approach to hematochezia beginning with colonoscopy should be more effective, safer, and less costly than one beginning with flexible sigmoidoscopy, even when the blood is bright red.

Adolescent↗
PubMed2000

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding.

OBJECTIVE: This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding. METHODS: One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus. RESULTS: In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids. CONCLUSIONS: In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.

Adolescent↗
PubMed1983

The value of colonoscopy and double-contrast barium-enema examinations in the evaluation of patients with subacute and chronic lower intestinal bleeding.

We examined 136 consecutive patients with histories of guaiac positive stool examinations, bright red blood per rectum, or hematochezia to determine the value of the double-contrast barium-enema (DC-BE) examination and colonoscopy/proctoscopy in establishing bleeding sites. If examination findings were analyzed in conjunction with findings of visual examination of the anal area, the difference in the respective sensitivities of the two examinations was not statistically significant. If findings at the visual inspection were excluded, the DC-BE examination missed 45 of 155 proved bleeding sites (sensitivity, 71%) and 13 of 35 nonbleeding lesions (sensitivity for all lesions 70%), while colonoscopy missed 13 of 155 bleeding sites (sensitivity, 92%) and seven of 35 nonbleeding lesions (sensitivity for all lesions, 90%). The sensitivity of both methods was similar if all rectal and anal lesions were excluded. Only eight additional lesions (all polyps) were found in 78 patients who had bleeding internal and external hemorrhoids, anal fissures, and anal tears, and seven of these were found in patients who were older than 50 years of age. We conclude that colonoscopy is superior to the DC-BE examination in the detection of bleeding sites but similar in results to the DC-BE examination if lesions in the anal canal and rectum are excluded. The routine use of the DC-BE examination in patients with superficial lesions in the anal canal should be discouraged unless the patient has persistent bleeding or is 50 years old or older.

Adult↗
PubMed1987

Interventional colorectal endoscopic procedures: residual lesions on follow-up double-contrast barium enema study.

Endoscopic procedures such as deep rectal biopsy, sclerosant injection, or banding of hemorrhoids, and the electrocoagulation of small polyps leave residual abnormalities that will be apparent on double-contrast barium enema examinations performed a short time thereafter. Nine cases are described to illustrate the findings that may be encountered. Their recognition is important to prevent diagnostic confusion, and endoscopists should inform radiologists of any procedure performed.

Adult↗
PubMed1999

Ambulatory radical hemorrhoidectomy: personal experience with 1,530 Milligan-Morgan operations with follow-up of 2-15 years.

BACKGROUND/AIM: The aim of this study is to document experience in performing ambulatory hemorrhoidectomy under local anesthesia and to examine its feasibility. METHOD: 1,530 patients with symptomatic grade III-IV internal hemorrhoids underwent surgical hemorrhoidectomy (Milligan-Morgan) between 1976 and 1991. This was done in the jackknife position under local anesthesia. RESULT/CONCLUSION: The Milligan-Morgan hemorrhoidectomy is radical and easy to perform in a jackknife position under local anesthesia in an ambulatory setting.

Adult↗
PubMed1986

Voiding disturbances following anal surgery.

Voiding disturbances following anal surgery are a well known but often ignored condition. Thirty-seven patients were investigated before and after operation for hemorrhoids by uroflowmetry and measurement of residual urine. Sixteen patients showed a decreased peak flow after operation, 13 patients had residual urine of more than 100 ml and 5 patients developed urinary retention. Five of the 13 patients complained of stranguria, incontinence, nocturia and frequency during the following months. We suggest that patients with urological problems after anal surgery should have their bladder controlled at regular intervals.

Adolescent↗
PubMed2002

New approaches in ambulatory proctology.

Ambulatory proctology is till now very underestimated discipline, which is out of interest of big surgeons. But is is a very important field due to incidence of proctological affections and severe social consequences of their inappropriate diagnosis and treatment. We stress the conservative and semi-invasive treatment of hemorrhoids, anal thrombosis and anal fissures. We also mention the other anal pathologies.

Fissure in Ano↗
PubMed1984

Common anorectal disorders.

Anorectal disorders include a diverse group of pathologic processes that are frequently encountered in general medical practice but are poorly understood. The optimal management of anal pain, itching, bleeding, and incontinence is based on sound anatomic and pathophysiologic principles. Advances have been made in understanding the pathogenesis and management of four anorectal disorders frequently encountered by internists: hemorrhoids, fissures, pruritus, and incontinence.

Anal Canal↗
PubMed1975

Anorectal and perianal complications of hematologic malignant neoplasms.

Among 17 adults with hematologic malignant neoplasms in whom anorectal complications developed, the overall mortality was 53%; for those in whom the disease was not in remission the mortality was 69%, compared with zero for patients who were in remission. All but one of the deaths were directly attributable to septicemia secondary to the anorectal lesion. Over half of the patients had a history of previous anorectal problems or disordered bowel pattern preceding the anorectal complication. The anorectal lesions affecting these 17 patients included prolapsed hemorrhoids (in 5); discrete ulcers in the anal canal and surrounding cellulitis (8); necrosis of the anus and perianal area (2); and perirectal abscesses (2). Only the abscesses responded to surgical drainage. Treatment of the other lesions was conservative: bowel function was maintained as normal as possible, good perineal hygiene was practised and stool softeners were used, while efforts were directed towards achieving remission of the hematologic neoplastic disease.

Adult↗
PubMed1997

[Primary curative incision in the treatment of perianorectal abscess].

More than 50% of the patients with perianorectal abscess treated with traditional incisional drainage will lead to fistula formation postoperatively. We present a procedure of primary curative incision for treatment with perianorectal abscess without fistula formation. The result of primary curative incision in comparison with traditional incisional drainage in a randomized control study showed that the incidence of postoperative fistula formation and recurrent abscess was 2.56% in the former and 56.25% in the latter. The key points of the procedure were discussed in detail and the causes and prevention of the disease occurred after injection of sclerotic drugs for hemorrhoids were also discussed.

Abscess↗
PubMed2000

[Hemorrhoidectomy using a circular stapler].

We compared traditional local excision of hemorrhoids in 40 patients (group A) with excision using the CDH-33 surgical stapler designed for bowel anastomosis, in 41 (group B). In this technique a purse-string suture is prepared 3 cm above the dentate line, and the stapler is inserted and used to form a mucosa-mucosal anastomosis. This technique is less time-consuming than the traditional technique. Data were collected from patients' medical files and from detailed questionnaires in which symptoms prior to and after operation were reported. Mean ages were 53.0 and 51.5 years and male/female ratios were 1.0:1.2 and 1.0:1.1 respectively, neither significant. The most common complaints in both groups were pain and rectal bleeding. All patients had a lower-GI investigation prior to operation to exclude other causes of rectal bleeding. Recovery averaged 2 months in both groups. Patient satisfaction was assessed by decrease or absence of symptoms on return to normal daily activities. Satisfaction tended to be greater in group B. More patients in group A complained of tightness and discomfort at the operative site, but this was not significant. We are extending our study to a larger number of patients to determine if there are statistically significant differences between the results of the 2 methods.

Adult↗
PubMed2000

[Hemorrhoidectomy with ropivacaine (Naropin) local anesthesia. Preliminary experience].

BACKGROUND: The use of local anesthesia in non-septic anal surgery is now well established. Tolerance to local injection, duration of local effect and the risk of local or systemic complications still represent unsolved issues. Ropivacaine, a new local anesthetic, seems particularly indicated for this kind of surgery because of its pharmacologic properties which reduce patient's discomfort during infiltration and provide good antalgic coverage in the first hours following the operation. METHODS: The first 20 consecutive cases operated with local anesthesia by ropivacaine have been prospectively studied. All patients have been given an 11-point box VAS scale which is used for subjective evaluation of pain. RESULTS: Mean pain score resulted 1.1, 1.6 and 1.4 at 1, 2 and 3 postoperative hours, respectively. Thirty percent of patients subsequently required pain medication up to the first bowel movement. No complications related to the use of ropivacaine has been observed. CONCLUSIONS: This new drug can be safely used in the outpatient or Day-Surgery treatment of hemorrhoids.

Adult↗